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Section 3.17 Transition of Persons

3.17.1 Introduction
3.17.2 References
3.17.3 Scope
3.17.4 Did you know…?
3.17.5 ObjectivesDefinitions
3.17.6 DefinitionsObjectives
3.17.7 Procedures
3.17.7-A. Transition from child to adult services
3.17.7-B. Transition due to a change of the clinical liaison, a pBehavioral Health Provider or the behavioral health category assignment
3.17.7-C. Transition to ALTCS Program Contractors
3.17.7-D. Inter-T/RBHA Transfer
3.17.7-E. Transitions of persons receiving court ordered services

3.17.1 Introduction
Persons receiving behavioral health services in the Arizona Department of Health Services/Division of Behavioral Health Services (ADHS/DBHS)system may experience transitions during the course of their care and treatment. Examples of transitions of care include changing service providers, establishing eligibility under Arizona Long Term Care Services (ALTCS), transitioning into adulthood, and moving out of the T/RBHA’s geographic service area. During transitions of care, behavioral health providers must ensure that services are not interrupted and that the person continues to receive needed behavioral health services. Coordination and continuity of care during transitions are essential in maintaining a person’s stability and avoiding relapse or decompensation in functioning.

The intent of this section is to:

  • Identify the situations that require a transition of care;
  • Describe expectations for providers when initiating or accepting a transition of care for an enrolled person; and
  • Identify resources to assist behavioral health providers in supporting a person who is experiencing a transition of care.

3.17.2 References
The following citations can serve as additional resources for this content area:

  • A.R.S. § 36, Chapter 5
  • 9 A.A.C. 21, Article 5
  • AHCCCS/ADHS Contract

ADHS/RBHA Contract

  • ADHS/T/RBHA ContractIGAs
  • ADHS/Gila River Health Care Corporation Intergovernmental Agreement
  • ADHS/Pascua Yaqui Behavioral Health Program Intergovernmental Agreement
  • Section 3.2, Appointment Standards and Timeliness of Services

Section 3.3, Intake and Referral Process

  • Section 3.4, Co-payments
  • Section 3.7, Clinical Liaison
  • Section 3.8, Outreach, Engagement, Re-Engagement and Closure
  • Section 3.10, SMI Eligibility Determination
  • Section 3.18, Pre-petition Screening, Court Ordered Evaluation and Treatment
  • Section 3.21, Service Prioritization for Non-Title XIX/XXI Funding
  • Section 4.1, Disclosure of Behavioral Health Information
  • Section 5.5, Notice and Appeal Requirements (SMI and Non-SMI/Non-Title XIX/XXI)
  • Section 7.5, Enrollment, Disenrollment and other Data Submission
  • Transitioning to Adult Services Practice Improvement ProtocolPractice Protocol, Transition toAdulthood
  • ADHS/DBHS Policy Clarification Memorandum: Inter-RBHA Coordination of Service

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3.17.3 Scope
To whom does this apply?

All persons, regardless of funding source or behavioral health category, currently enrolled with a T/RBHA and experiencing a transition of care.

3.17.4 Did you know?

  • Some persons may experience a transition of payers, but not actually change providers. This could happen, for example, when a Title XIX behavioral health recipient moves from anArizona Health Care Cost Containment System(AHCCCS) acute care Health Plan to the ALTCS program. Many ALTCS Program Contractors for the elderly and physically disabled (ALTCS/EPD) contract with the same behavioral health providers as the T/RBHAs. This kind of transition, where fiscal responsibility changes but not the provider, may be transparent to the person receiving services, but could result in administrative changes for the provider (e.g., submitting claims or bills to the ALTCS Program Contractor versus submitting an encounter as a T/RBHA provider).
  • The ALTCS program is considered a “carve-in model,” a service delivery model that assigns coverage of medical and behavioral health services through a single entity (i.e., Program Contractor). An exception to this “carve-in model” is the delivery of covered behavioral health services for persons eligible for ALTCS through the Division of Developmental Disabilities (DDD). ALTCS/DDD eligible persons receive covered behavioral health services through the RBHAs and their subcontracted behavioral health providers.

Accurate diagnosis of a co-occurring serious mental illness can be difficult when the person has been diagnosed with a developmental disability, which includes Autism and Cognitive Disability. Psychiatric symptoms are often inaccurately attributed to a person’s developmental disability rather than a serious mental illness. All diagnoses that can be made of persons of normal intelligence can also be made in a person with a developmental disability. TheDiagnostic Manual: Intellectual Disabilities (DM: ID), published in 2008, may be a useful resource in the diagnosis of mental illness in a person with a developmental disability

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3.17.56Objectives
To ensure the coordination and continuity of care for personsall behavioral health recipientsexperiencing a transition in service providers.

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3.17.65Definitions
Behavioral Health Category Assignment

Clinical Liaison

Designated T/RBHA

Home T/RBHA

Independent Living Setting

Institution for Mental Disease (IMD)

Out-of-area service

Residence

Serious Mental Illness (SMI)

Transfer

3.17.7 Procedures

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3.17.7-A. Transition from child to adult services
When a child who has been involved in long term or intensive behavioral health care reaches the age of 16, planning for the transition into the adult behavioral health system must begin. A transition plan that starts with an assessment of self-care and independent living skills, social skills, work and education plans, earning potential and psychiatric stability must be incorporated in the child’s individual service plan.

Planning for the transition into the adult behavioral health system must begin for any child involved in behavioral health care when the child reaches the age of 16. Planning must begin immediately for youth entering behavioral health care who are 16 years or older at the time they enter care.

A transition plan that starts with an assessment of self-care and independent living skills, social skills, work and education plans, earning potential and psychiatric stability must be incorporated in the child’s individual service plan (ISP).

What elements should be addressed as part of the child’s transition plan?
Some of the elements to be addressed by the Child and Family Team and/or Clinical Liaison as part of a transition plan include:

Not all children transfer to the adult Serious Mental Illness (SMI) or General Mental Health/Substance Abuse (GMH/SA) system, but for children who do, providers must ensure a smooth transition. In order to accomplish a smooth transition, providers must develop a clear and explicit process and procedure that will ensure and support the delivery of children’s and adult services during the transition period. Providers must ensure that adult system staff attend and are a part of the Child and Family Team (CFT) (during the four to six months prior to the child turning 18) in order to provide information and be part of the service planning, development and coordination effort that needs to take place so the individualized needs of that child can be met on the day they turn 18 years of age.

  • What are likely to be the child’s behavioral health needs into adulthood?
  • What personal strengths will assist the child when he/she transitions to the adult system?
  • Will there be a change in provider, the clinical team, family involvement, and/or the clinical liaison? How will the transition be implemented?
  • Where will the child reside upon turning 18 and how will he/she support him/herself?
  • Will the child need referrals to and assistance with applications for Supplemental Security Income (SSI), Rehabilitation Services Administration (RSA), Serious Mental Illness (SMI) eligibility determination, Title XIX and Title XXI eligibility, housing, guardianship, training programs, etc.? Are there medical and school records to substantiate these needs? Begin to gather necessary information to expedite these applications/determinations when the time comes to actually apply. Develop a timeline and task list for when appointments are needed.
  • Will the child have or need transportation to appointments and other necessary activities?
  • Does the child have special needs or will the child require special assistance services?
  • Does the child have appropriate life skills, social skills and employment or education plans?
  • What actions need to be taken if the child is not eligible for Title XIX or Title XXI benefits and/or Social Security Disability Income (SSDI) and is not determined to have a serious mental illness?
  • What supports need to be in place for a successful transition?
  • If an SMI eligibility determination is made, consider initiating a referral for housing, if needed.

Some of the elements to be addressed by the CFT and/or Behavioral Health Provider as part of a transition plan include:

  • Identifying the child’s behavioral health needs into adulthood.
  • Identifying personal strengths that will assist the child when he/she transitions to the adult system.
  • Identifying staff that will coordinate services after the child reaches age 18, including any changes in the behavioral health provider, clinical team, guardian or family involvement.
  • Identifying and collaborating with other involved state agencies and stakeholders to jointly establish a behavioral health service plan and prevent duplication of services.
  • Establishing how the transition will be implemented.
  • Planning for where the child will reside upon turning 18 and how he/she will support him/herself. If an SMI eligibility determination is made, consider initiating a referral for housing, if needed.
  • Identifying the need for referrals to and assistance with applications for Supplemental Security Income (SSI), Rehabilitation Services Administration (RSA), SMI eligibility determination, Title XIX and Title XXI eligibility, housing, guardianship, training programs, etc. In addition, the team and/or behavioral health provider should assist in gathering necessary information to expedite these applications/determinations when the time comes to actually apply, including obtaining medical and school records to substantiate these needs. The team and/or behavioral health provider begin to develop a timeline and task list for when appointments are needed.
  • Identifying the need for transportation to appointments and other necessary activities.
  • Identifying special needs that the child may have and/or whether or not the child will require special assistance services.
  • Identifying whether the child has appropriate life skills, social skills and employment or education plans.
  • Taking necessary action if the child is not eligible for Title XIX or Title XXI benefits and/or Social Security Disability Income (SSDI) and is not determined to have a SMI. Identifying supports needed to be in place for a successful transition.
  • Following guidelines established in ADHS/DBHS Clinical and Recovery Practice Protocol, Transition to Adulthood.
  • Meeting the provisions of the JK Settlement Agreement[1] and the Arizona 12 Principles.

The services that have been planned, developed and provided for the child can continue to be provided after the child has turned 18 years of age, assuming that continuation of these services is the choice of the young person when he/she reached the age of majority. Providers shall properly encounter and receive payment for the provision of services of staff involved, including adult system staff, according to T/RBHA procedures included in Section 10.0, T/RBHA Specific Requirements (see for a listing of T/RBHA provider manuals)

Providers are responsible for the provision of services for Title XIX/XXI eligible members 18 years of age through 20 years of age (who are still a part of the Early Periodic Screening, Diagnosis, and Treatment (EPSDT) program) regardless of their designation as SMI or GMH/SA. Services include case management services and all other covered services that the person’s treatment team determines to be needed to meet individualized needs

What needs to happen during the year before the child transitions to adult services?

  • When a child receiving behavioral health services reaches the age of 17, behavioral health providers must determine whether the child is potentially eligible for services as an adult with a sSerious mMental iLllness. If so, behavioral health providers must refer the child for an SMI eligibility determination pursuant to Section 3.10, SMI Eligibility Determination.
  • When a child receiving behavioral health services reaches 17 and a half, the Child and Family Team and/or the clinical liaisonCFT and/or the behavioral health providermust:
  • Assist the child and/or family or guardian in applying for potential benefits (e.g., SSI, food stamps, etc.);
  • Assist the child and/or family in applying for Title XIX or Title XXI benefits; if the child and/or family is already eligible, determine if eligibility will continue for the child once he/she turns 18;
  • Address any new authorization requirements for sharing protected health information due to the child turning 18 (as described in Section 4.1, Disclosure of Behavioral Health Information) to ensure that the clinical team can continue to share information;
  • Ensure that the child’s behavioral health category assignment is changed consistent with Section 7.5, Enrollment, Disenrollment and other Data Submission. Once the child’s behavioral health category assignment has been changed, ongoing behavioral health service appointments must be provided according to the timeframes for routine appointments in Section 3.2, Appointment Standards and Timeliness of Services; and
  • Upon turning 18 years of age, if the person is not eligible for services as a person determined to have a sSerious mMental iIllness or the person has been determined ineligible for Title XIX or Title XXI services, behavioral health providers can continue to provide behavioral health services consistent with Section 3.21, Service Prioritization for Non-Title XIX/XXI Funding and Section 3.4, Co-payments.

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3.17.7-B: Transition due to a change of the clinical liaison,Behavioral Health Providera provider or the behavioral health category assignment
Upon changes of a person’s clinical liaison,behavioral healthprovider or behavioral health category assignment, the clinical liaisonbehavioral health providermust:

  • Review the current individual service plan and, if needed, coordinate the development of a revised individual service plan with the person, clinical team and the receiving clinical liaisonbehavioral health provider;
  • Ensure that the person’s comprehensive clinical record is transitioned to the receiving clinical liaisonbehavioral health provider;
  • Ensure the transfer of responsibility for court ordered treatment, if applicable; and
  • Coordinate the transfer of any other relevant information between clinical liaisonsthe behavioral health providerand otherprovider agencies, if needed.

The assigned Gila River RBHA Clinician acts in the capacity of clinical liaison for all RBHA enrolled persons. Prior to the assignment of a RBHA Clinician, the RBHA staff person who completes the initial assessment serves as the person’s clinical liaison.

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3.17.7-C: Transition to ALTCS Program Contractors
This section does not apply to persons enrolled in the Arizona Long Term Care Services/Division of Developmental Disabilities (ALTCS/DDD). ALTCS/DDD eligible persons receive all covered behavioral health services through T/RBHAs and their contracted providers.

Once a person is determined eligible and becomes enrolled with the Arizona Long Term Care Services/Elderly or Physically Disabled (ALTCS/EPD) Program, behavioral health providers must not submit claims or encounters for Title XIX covered services to the T/RBHA. To determine if a person is ALTCS/EPD eligible, call (602) 528-7141. The behavioral health provider must, however, continue to provide and encounter needed non-Title XIX covered SMI services (e.g. housing) to persons determined to have a sSerious mMental iIllness.

Behavioral health providers who contract as an ALTCS provider must not submit encounters for an ALTCS/EPD enrolled person to the T/RBHA after a person transfers to ALTCS, but must submit bills/claims for payment to the ALTCS Program Contractor who in turn submits the encounters to AHCCCS.

When a person who has been receiving behavioral health services through the T/RBHA becomes enrolled in the ALTCS Program, the clinical liaisonbehavioral health providermust:

  • Include the member in transition planning and provide any available information about changes in physician, services, etc.;
  • Ensure that the clinical and fiscal responsibility for Title XIX behavioral health services shifts to the ALTCS Program Contractor;
  • Provide information to the ALTCS Program Contractor regarding the person’s on-going needs for behavioral health services to ensure continuity of care during the transition period;
  • Review the current treatment plan and, if needed, coordinate the development of a revised treatment plan with the clinical team and the receiving ALTCS provider and/or case manager;
  • Transfer responsibility for any court ordered treatment;
  • Coordinate the transfer of records to the ALTCS program contractor; and
  • Provide information as follows:
  • For Title XIX eligible 21-64 year olds, the number of days the person has received services in an Institution for Mental Disease (IMD) in the contract year (July 1 – June 30)
  • For all persons, the number of hours of respite received in the contract year (July 1 – June 30); and
  • Whether there is a signed authorization for the release of information contained in the comprehensive behavioral health record pursuant to Section 4.1, Disclosure of Behavioral Health Information.

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3.17.7-D Inter-T/RBHA Transfer
How is T/RBHA responsibility determined for adults?

For adults (persons 18 years and older), T/RBHA responsibility is determined by the adult person’s current place of residence, except in the following situation:

  • Persons who are unable to live independently must not be transferred to another T/RBHA with the exception of persons who are unable to live independently but are involved with the Division of Developmental DisabilitiesDDD. However, T/RBHAs may agree to coordinate an Inter-T/RBHA transfer for individuals unable to live independently on a case-by-case basis.Persons involved with DDD who reside in a supervised setting are the responsibility of the T/RBHA in which the supervised setting is located. This is true regardless of where the adult guardian lives.When an ALTCS/DDD member is placed temporarily in a group home while a permanent placement is being developed in the home T/RBHA service area, covered services remain the responsibility of the home T/RBHA.

How is T/RBHA responsibility determined for children?